Enclosure D. Vendor ACH Authorization Form.pdf

This is a Vendor ACH Authorization Form used by Brookhaven National Laboratory (BNL), managed by Brookhaven Science Associates, LLC under contract with the U.S. Department of Energy, to establish electronic payment processing for vendors.

The form requires vendors to provide standard identification information including company name or DBA, vendor number (if applicable), and Tax ID Number (TIN). In the Depository Information section, vendors must supply their financial institution details, including the routing/transit/ABA number and checking account number. By signing the authorization, vendors grant BNL/BSA permission to initiate ACH (Automated Clearing House) credit entries and correcting entries to the designated account. The authorization remains in effect until BNL/BSA receives written notification to terminate or modify it, and vendors understand that credit authorizations may be revoked only through notification to the originator as governed by NACHA (National Automated Clearing House Association) law. The form must be completed and signed by an authorized representative who provides their name, email address, phone number, signature, and date.